2020/2021 Summary of Benefits...July 1, 2020 - June 30, 2021 2020/2021 Summary of Benefits SCAN Retiree Group - LACERA (HMO) is an HMO plan with a Medicare contract. Enrollment in

SCAN Retiree Group

Los Angeles County Employees Retirement Association(LACERA) (HMO)July 1, 2020 - June 30, 2021

2020/2021 Summary of Benefits

SCAN Retiree Group - LACERA (HMO) is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage” by calling our Member Services Department at the phone number listed in this document or online at www.scanhealthplan.com.

Y0057_SCAN_11865_2020F_M IA 04292020 R1328 05/20 21EG-SMB105

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PREMIUM AND BENEFITS LACERA WHAT YOU SHOULD KNOW

Monthly Health Plan Premium For premium information, please contact your Plan Sponsor Benefits Administrator.

You must continue to pay your Medicare Part B premium.

Deductible You pay $0 This plan does not have a deductible.

Maximum Out-of-Pocket Responsibility (this does not include prescription drugs)

$3,400 annually The most you pay for copays and coinsurance for Medicare-covered medical services for the year.

Inpatient Hospital Coverage You pay $0 Our plan covers an unlimited number of days for an inpatient hospital stay. Prior authorization rules apply.

Outpatient Hospital Coverage

• Ambulatory Surgical Center You pay $0 per visit

Prior authorization is required for outpatient hospital visits.

• Outpatient Hospital You pay $0 per visit

Doctor Visits

• Primary Care You pay $5 per visit

Prior authorization is required for specialist visits.

• Specialists You pay $5 per visit

Preventive Care You pay $0 Any additional preventive services approved by Medicare during the contract year will be covered. Prior authorization rules apply.

Emergency Care You pay $25 copay per visit

The emergency room copay will be waived if you are immediately admitted to the hospital. You are covered for worldwide emergency services.

Urgently Needed Services You pay $25 copay per visit

You are covered for worldwide urgent care services.

SUMMARY OF BENEFITS JULY 1, 2020 - JUNE 30, 2021

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Diagnostic Services/Labs/Imaging

• Lab services You pay $0

Prior authorization is required for diagnostic, lab, and imaging services.

• Diagnostic tests and procedures

You pay $0

• Outpatient x-rays You pay $0

• Therapeutic radiology You pay $0

• Diagnostic radiology (e.g., MRI, CT)

You pay $0

Hearing Services

• Medicare-covered diagnostic hearing and balance exam

You pay $5 copay per visit

Prior authorization is required for Medicare-covered diagnostic hearing and balance exams.

You must go to a SCAN-contracted provider to obtain a routine hearing exam and hearing aids.

• Non-Medicare-covered (routine) hearing exam

You pay $5 copay for up to 1 visit per year

• Non-Medicare-covered (routine) hearing aid fitting/evaluation

You pay $5 copay for up to 3 visits within the first year of purchase

• Non-Medicare-covered (routine) hearing aids

You are covered up to $600 for up to 2 hearing aids every 2 years

Dental Services

• Medicare-covered dental services


Prior authorization is required for Medicare-covered dental services.

• Non-Medicare-covered (routine) oral exam and cleaning

Not covered

• Non-Medicare-covered (routine) dental cleanings

Not covered

• Non-Medicare-covered (routine) dental x-rays

Not covered

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Vision Services

• Medicare-covered vision exam to diagnose/treat diseases of the eye


Prior authorization is required for Medicare-covered vision exams and glasses after cataract surgery.

• Medicare-covered glasses after cataract surgery

You pay $5 copay per pair

• Non-Medicare-covered (routine) vision exam

Not covered

• Non-Medicare-covered (routine) glasses or contact lenses

Not covered

• Non-Medicare-covered (routine) vision coverage limit

Not covered

Mental Health Services

• Inpatient visit You pay $0

Prior authorization is required for inpatient mental health hospitalization. You are covered for up to 90 days per benefit period.*

• Outpatient individual/group therapy visit


Prior authorization is required for outpatient mental health services.

• Outpatient individual/group therapy visit with a psychiatrist


Skilled Nursing Facility You pay $0 for days 1-100

Prior authorization is required for skilled nursing facility services. You are covered for up to 100 days per benefit period.*

No prior hospitalization is required.

Physical Therapy You pay $5 copay per visit

Prior authorization is required for physical therapy services.

*A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row.

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Ambulance You pay $0 per one-way trip

Transportation (Non-Medicare-covered - routine)

You pay $0 for unlimited trips per year

75-mile limit applies to each one-way trip

Prior authorization is required for routine transportation services.

You must use a SCAN-contracted provider to obtain routine transportation services.

Medicare Part B Drugs You pay $0 for chemotherapy and other Part B drugs

Prior authorization or step therapy rules apply to select drugs.

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You pay the following:

LACERA

Preferred Retail Pharmacy 30-day supplycost-sharing

Standard Retail Pharmacy 30-day supply cost-sharing

Preferred Retail Pharmacy 90-day supply cost-sharing

Standard Retail Pharmacy 90-day supply cost-sharing

Mail-Order Pharmacy 90-day supply cost-sharing

Initial Coverage Stage

Tier 1 (Preferred Generic)

You pay $2 You pay $7 You pay $4 You pay $7 You pay $4

Tier 2 (Generic) You pay $2 You pay $7 You pay $4 You pay $7 You pay $4

Tier 3 (Preferred Brand)


Tier 4 (Non-Preferred Drug)


Tier 5 (Specialty Tier)

You pay $15 You pay $15 Not available Not available Not available

Catastrophic Coverage Stage You stay in the Initial Coverage Stage until your yearly out-of-pocket costs reach $6,350. After your yearly out-of-pocket drug costs reach $6,350, you pay whichever is the larger amount:

– 5% of the cost, or

– $3.60 copay for generic (including drugs that are treated like a generic) and $8.95 copay for all other drugs.

Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs if you use these pharmacies. Cost-sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information, please call our Member Services Department at the number provided in this document or access your Evidence of Coverage online.

You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

Your Cost-Sharing may differ depending on the pharmacy you choose (e.g., Preferred Retail, Standard Retail, Mail-Order, Long Term Care (LTC) or Home infusion, etc.) and whether you receive a 30- or 90-day supply. For more information on the pharmacy-specific copays, please call SCAN Member Services Department at the phone number in this document or access your Evidence of Coverage online.

Outpatient Prescription Drugs

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Medical Equipment/Supplies

• Durable medical equipment (e.g., wheelchairs, oxygen)

You pay $0

Prior authorization is required for covered durable medical equipment, prosthetic devices, and certain diabetic supplies.

SCAN covers diabetic supplies such as glucose monitors, test strips, and control solution from a select manufacturer. Lancets are also covered and are available from all manufacturers.

• Prosthetics (e.g., braces, artificial limbs)

You pay $0

• Diabetic supplies You pay $0

Telehealth Services - MDLive You pay $0 A visit with a board-certified doctor in the comfort of your own home. This benefit is for non-life threatening conditions such as, but not limited to, cough, flu, nausea, sore throat, fever, and allergies.

Visits with doctors can be conducted either by telephone or secure video capabilities from your computer or smart phone.

Wellness Programs

• Health club membership You pay $0

You are covered for SCAN-contracted health clubs in your area.

Additional Benefits

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Independent Living Power/Long Term Services and Supports (ILP/LTSS)*

SCAN Health Plan offers unique home and community-based services designed to keep you healthy and independent. These services are offered under the Independent Living Power/Long Term Services and Supports (ILP/LTSS) program.

Qualifying members are eligible for up to $650 per month of these additional services. Services are only available in Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties, California.

Please Note: You must be eligible to qualify for ILP/LTSS. An initial assessment is required. Once you are enrolled with ILP/LTSS, you must agree to receive your personal care and related homemaking services from SCAN Health Plan. Contact SCAN Member Services for details.

Homemaker ServiceYou are eligible to receive assistance with light cleaning, grocery shopping, laundry and meal preparation.

You pay $15 per visit

Home Delivered MealsYou are covered for home delivery of meals to meet nutritional needs.

You pay $0

Personal Care ServicesYou are covered for in-home assistance for tasks such as bathing, dressing, eating, getting in and out of bed, moving about/walking, and grooming.


Emergency Response SystemYou are covered for the installation of a personal emergency response device that alerts emergency medical personnel to provide immediate help. There is no cost for installation.

You pay $0

Transportation Escort ServicesYou are eligible to receive an escort to assist you during transportation to and from medical appointments.


Personal Care CoordinatorSCAN staff will provide personal assistance to coordinate your Independent Living Power/Long Term Support Services.

You pay $0

*Members who qualify for Independent Living Power/Long Term Services and Supports must meet state criteria for Nursing Home Certifiable as determined by a SCAN Specialist after enrollment in the plan. Copayments apply for most services. Limits also apply. Services available only in Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties, California.

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Inpatient Custodial CareYou are covered for up to 5 days per year for post-acute or respite support in a skilled nursing facility. You may use this service following a hospital discharge, ER visit, or for respite care purposes.

You pay $0

In-Home Caregiver ReliefSCAN provides alternative caregiver services in your home when a regular caregiver can’t be there.


Community-Based Adult Services (CBAS)-Adult Day CareSCAN covers adult day care services to provide relief for your regular caregiver while addressing the individual needs of the member for physical, social or intellectual exercises and stimulation. Criteria applies.


Incontinence SuppliesMembers who qualify may be eligible to receive selected incontinence supplies, such as diapers, briefs, and pads to maintain skin integrity.

You pay $0

Select Bathroom Safety EquipmentMembers may be eligible to receive selected bathroom safety equipment to assist you in performing certain daily activities. Please contact your Care Manager for further information.

You pay $0

*Members who qualify for Independent Living Power/Long Term Services and Supports must meet state criteria for Nursing Home Certifiable as determined by a SCAN Specialist after enrollment in the plan. Copayments apply for most services. Limits also apply. Services available only in Los Angeles, Orange, Riverside, San Bernardino, and San Diego counties, California.

Independent Living Power/Long Term Services and Supports (ILP/LTSS)*

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Who can join? You must:

- have both Medicare Part A and Part B

- live in the plan service areas (Los Angeles, Orange, Riverside, San Bernardino, San Diego, Ventura, Santa Clara, San Francisco, Napa, Sonoma, and Stanislaus counties, California)

- be a United States citizen or be lawfully present in the United States

- not be medically determined to have end-stage renal disease (ESRD)

Phone Number (Members)

Phone Number (Non-Members)

TTY

1-800-559-3500

1-877-685-7226Calling this number will direct you to a licensed insurance agent.

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Hours of Operation October 1 to March 31: 8 a.m. to 8 p.m., 7 days a week

April 1 to September 30:8 a.m. to 8 p.m., Monday through Friday Messages received on holidays and outside of our business hours will be returned within one business day.

Website www.scanhealthplan.com

SCAN Retiree Group - LACERA has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

To get more information about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at https://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048.

You can get prescription drugs shipped to your home through our network mail-order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan Member Services at 1-800-559-3500 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day).

About SCAN

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SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of, or because of, race, color, national origin, age, disability, or sex.

SCAN Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

SCAN Health Plan provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact SCAN Member Services.

If you believe that SCAN Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, or fax, at:

SCAN Member Services Attention: Grievance and Appeals Department P.O. Box 22616, Long Beach, CA 90801-5616 1-800-559-3500 (TTY: 711) FAX: 1-562-989-5181

Or by filling out the “File a Grievance” form on our website at: https://www.scanhealthplan.com/contact-us/file-a-grievance

If you need help filing a grievance, SCAN Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 (TTY: 1-800-537-7697)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal.

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-877-230-7226 (TTY: 711). Hours are 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30 hours are 8 a.m. to 8 p.m., Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one business day.

Understanding the Benefits

oReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit www.scanhealthplan.com or call 1-877-230-7226 to view a copy of the EOC.

oReview the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

oReview the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

oIn addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

oBenefits, premiums and/or copayments/co-insurance may change on July 1, 2021.

oExcept in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).

Pre-Enrollment Checklist

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SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of, or because of, race, color, national origin, age, disability, or sex.

SCAN Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

SCAN Health Plan provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact SCAN Member Services.

If you believe that SCAN Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, or fax, at:

SCAN Member Services Attention: Grievance and Appeals Department P.O. Box 22616, Long Beach, CA 90801-5616 1-800-559-3500 (TTY: 711) FAX: 1-562-989-5181

Or by filling out the “File a Grievance” form on our website at: https://www.scanhealthplan.com/contact-us/file-a-grievance

If you need help filing a grievance, SCAN Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019 (TTY: 1-800-537-7697)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal.

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English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-559-3500. (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-559-3500. (TTY: 711).

Chinese Traditional: 注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-800-559-3500。(TTY: 711)。

Chinese Simplified: 注意：如果您使用中文，您可以免费获得语言援助服务，请致电 1-800-559-3500。(TTY: 711)。 Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin vui lòng gọi số 1-800-559-3500. (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-559-3500. (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-559-3500 번으로 연락해 주십시오. (TTY: 711).

Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարե'ք 1-800-559-3500 հեռախոսահամարով: Հեռատիպի համարն է՝ 711:

Persian: ت زبایی بوور ت راگگان گفتگو می کنید، تسهیال فارسیاگر به زبان :توجه .(TTY: 711) ماس بگیرگد.ت 3500-559-800-1شماره برای شما فراهم می باشد. با

Russian: ВНИМАНИЕ! Если вы говорите по-русски, вы можете бесплатно получить услуги перевод;а. Звоните по телефону 1-800-559-3500 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お問合せ先�1-800-559-3500. (TTY: 711).

Arabic: المساعدة اللغوية تتوافر لك ، فإن خدمات العربيةملحوظة: إذا كنت تتحدث (.711)الهاتف النصي: .3500-559-800-1 برقم اتصل بالمجان.

Punjabi: ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱ ਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-800-559-3500 ਉੱਤੇ ਕਾਲ ਕਰੋ। (TTY: 711)। Mon-Khmer, Cambodian: សូមយកចិត្តទុកដាក់៖ ប ើសិនជាអ្នកនិយាយភាសាខ្មែរ បសវាជំនួយខ្ននកភាសា បដាយមិនគិត្ថ្លៃ អាចមានសំរា ់ ំបរ ើអ្នក។ សូមទូរស័ព្ទបៅបេម 1-800-559-3500 ។ (TTY: 711) ។ Hmong: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav - Hmoob), muaj kev pab txhais lus pub dawb rau koj. Hu rau 1-800-559-3500. (TTY: 711). Hindi: ध्यान दें: यदद आप द िंदी बोलत े ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ैं। कॉल करें 1-800-559-3500, (TTY: 711)। Thai: โปรดทราบ: ถ้าคณุพดูภาษาไทย คณุสามารถใช้บริการชว่ยเหลือทางภาษาได้ฟรี โทร 1-800-559-3500 (TTY: 711) Lao: ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-559-3500 (TTY: 711).

Documents

2020/2021 Summary of Benefits...July 1, 2020 - June 30, 2021 2020/2021 Summary of Benefits SCAN Retiree Group - LACERA (HMO) is an HMO plan with a Medicare contract. Enrollment in